Assessment Of Health Education Outcomes About Dyslipidemia, Using A Network Of Community Health Workers In Hue City – Doan Phuoc Thuoc

467 JOURNAL OF SCIENCE, Hue University, N0 61, 2010 ASSESSMENT OF HEALTH EDUCATION OUTCOMES ABOUT DYSLIPIDEMIA, USING A NETWORK OF COMMUNITY HEALTH WORKERS IN HUE CITY Doan Phuoc Thuoc College of Medicine and Pharmacy, Hue University Nguyen Thi Kim Tien Vietnam's Ministry of Health SUMMARY Dyslipidemia is very common in the community and is an important risk factor of atherosclerosis and coronary artery disease with high mortality. A community intervention of health education is designed to progressively reduce dietary intake of satuprevalenced fats, cholesterol, total calories and increase physical activities to decrease dyslipidemia. The intervention was conducted by a network of medical staffs in wards and intergprevalence with other health programmes. After 12 months of intervention, the prevalence of dyslipidemia decreased 11.6% (from 39.3% to 27.7%). The prevalence of high serum total cholesterol (TC) levels reduced from 20.4% to 11.1%, LDL-C levels reduced from 15.7% to 6%, triglicerides levels did not change. Average values of serum HDL-C levels increased (from 53.6 mg / dL to 63.9 mg / dL) and LDL-C levels reduced (from 119.4 mg / dL to 100.6 mg / dL) (p <0.05); average values of TC and TG did not change. Dietary and physical activity habits reduced intake of satuprevalenced fats and alcohol, higher intake of vegetables, and fish. Higher prevalence of exercise and sports. Excessive intake of alcohol per day reduced from 37.1% to 6.6%. Knowledge of dyslipidemia, dietary and physical activity also improved. There was an increase in the prevalence of people who came clinic to test blood lipid by themselves (from 0.9% to 20.2%) and know results of the test (from 3.2% to 28.8%); an increase in prevalence of treatment dyslipidemia (from 2.3% to 16%); among of them, the application of lifestyle changes in treatment increased from 0.4% to 13.7% (p<0.05). Community health education on dyslipidemia based on a network of medical staff in wards improved the level of knowledge and behavior change surrounding the prevention and treatment of dyslipidemia, and effectively reduced the dyslipidemia prevalence in the community. 1. Introduction Dyslipidemia is very common in the community, and is called a “New World Syndrome” by World Health Organization . Dyslipidemia is an important risk factor of atherosclerosis and coronary artery disease with high mortality . Many studies show that 468 secondary causes (lifestyle habits) play an important role in the process of dyslipidemia, including high fat diet, sedentary lifestyle, few physical activities, drinking too much alcohol (lifestyle factors) and poor knowledge of dyslipidemia. The fact that changing lifestyle habits will reduce prevalence of dyslipidemia and coronary disease risk has been identified in developed countries. In Vietnam in general and Hue city particularly, the education program related to dyslipidemia is very limited, so detection, prevention and treatment of dyslipidemia does not receive adequate concern. Doctors in hospitals often use drugs to treat those individuals with dyslipidemia. It's important in health care strategy to reduce the morbidity in community and increase the prevalence of detection and treatment to have long term effects. The study "Assessment of health educational outcomes about dyslipidemia using a network of community health workers in Hue City" was conducted to assess the behavioral changes in prevention and treatment of dyslipidemia and evaluate the prevalence of dyslipidemia decreasing in people aged 20 years or older in Hue city through community health education. 2. Methodology - The subjects of the study were adults aged 20 years or older in Hue city - Study design: A community intervention of health education is designed to progressively reduce dietary intake of saturated fats, cholesterol, total calories and increase physical activities to decrease dyslipidemia; the intervention was conducted for 12 months from 3/2008 to 5/2009 by a network of medical staffs in wards and intergrate with other health programmes. - Sample size: 350 adults aged 20 and older, calculated by following formula 2 )1(2 d Fppn ▪ F = 7,9; d: difference between dyslipidemia prevalence before (pA) and after (pB) health education; pA : 35.08 % and pB : 25 % (expectantly) - Sample: Choose two wards of Hue city randomly, randomly select five groups (administrative units of ward) per ward, and 35 people aged 20 years and older per group selected according to a list - Methods of data collection: + A community survey to collect data before the community health education on dyslipidemia 469 + Implement health education programs based on a network of community health workers for 12 months + A community survey to collect data after 12 months of lipid education - The information collected + Personal information: age, gender, occupation + Eating habits, physical activity, drinking beer / wine + Knowledge about blood lipid and dyslipidemia + Test blood lipid, prevention and treatment of dyslipidemia + The prevalence of dyslipidemia, blood level of lipid components - Methods of research evaluation: + Comparison of previous and after index and prevalence of the application program for community health education on blood lipids and evaluate the difference between prevalences based on the P value < 0.05 and intervention effective (IE) 100 1 21 P pp IE P1: exposure prevalence in control group, P2: The prevalence of exposure in the education group - Health education on lipids Community communication and health education: + Public communication 6 times/ 12 months; + Play media, talk, leaflets at the meeting in wards and groups Consultation and communication at families: From March 2008 to 3 in 2009 + Medical staff of the ward to households integrated with implementation of other health programs to interview, discusion, guidance, encouragement, leaflets and video tapes for households. Communication in ward health centers, pharmacies, and private clinics - The concept of research variables + Blood lipid disorders classification: 470 Table 2.1. Blood lipid disorders classification: according to NCEP ATPIII 2002 LDL-C (mg/dL) <100 Optimal 100-129 Near Optimal 130-159 Borderline high 160-189 High 190 Very high CT (mg/dL) <200 Desirable 200-239 Borderline high 240 High HDL-C (mg/dL) <40 Low 60 High TG (mg/dL) <150 Desirable 150-199 Borderline high 200-499 High 500 Very high Source: Third Report of the National Cholesterol Education Program, 2002 + Physical activity level Sedentary: Typical daily living activities ( below 30 minutes per day) Low active: Sedentary plus 30 to 60 minutes of moderatedaily activity (e.g. brisk walking) Active: Low active plus at least 60 minutes of moderate daily activity (e.g. brisk walking) Very active: Active plus an additional 60 minutes of vigorous activity (e.g. jogging, biking) or 120 minutes of moderate activity (e.g. brisk walking) + Eating habit Habit of eating much vegetables, fat, sweet is like eating much vegetables or fat, or sweeteners and food continuously doesn’t make sense (4-7 days / week). 471 + The habit of drinking too much alcohol /beer/ wine: Drinking more than one cup (women) and two cups (male) of alcohol of all kinds per day, a cup being equivalent to 50ml of strong wine, equivalent to 150 ml of wine and 1 can of beer. + Knowledge of dyslipidemia: Evaluation of the three groups of knowledge: good knowledge, average, and bad, based on the following score scale Bad level: The total score of each answer (S) in each group is lower than the average of the sample (S <M) in the group that knowledge. Average level: M ≤ S ≤ M+SD (standard deviation) Good level: S > M+SD - Analysis and data processing: Using the SPSS 10.0 program and Epi info 6.04 3. Results 3.1. Results of behavioral change of prevention and treatment - Change of lifestyle habits on the sample before-after health education Table 3.1. The prevalence of lifestyle habits on the sample before-after health education Before health education (n= 350) After health education (n= 350) P (Chi- square) Lifestyle habits % % Eating High fat diet 35.6 16.6 <0.05 Much vegetables, fish 43.5 69.7 <0.05 Sweet and starch 9.7 7.4 >0.05 Undefined 11.1 6.3 <0.05 Physical activity No exercise 58.8 19.1 <0.05 Walk 33.3 71.1 <0.05 Badminton 6.9 5.4 >0.05 Running 0.5 2.8 <0.05 Others 0.5 1.5 <0.05 472 Level of physical activity/day Sedentary 26.9 2.9 <0.05 Low active 14.4 25.7 <0.05 Active 14.8 26.9 <0.05 Very active 44.0 44.6 >0.05 Drinking alchohol Too much 37.1 6.6 <0.05 Moderate 31.9 18.9 <0.05 No drinking 31.0 74.6 <0.05 After health education on blood lipids, the prevalence of participants eating high fat decreased from 35.6% to 16.6%; eating many vegetables, and fish increased from 43.5% to 69.7%. The prevalence of people who exercise and play sports increased. Brisk walking is common, the prevalence increased from 33.3% to 71.1%. The prevalence of people who were sedentary reduced from 26.9% to 2.9%, much drinking alcohol decreased from 37.1% to 6.6%, 3.2. Compare knowledge levels of dyslipidemia before - after health education Table 3.2. The prevalence of knowledge levels of dyslipidemia before - after health education Before health education (n= 350) After health Education (n= 350) P (Chi- square) Knowledge levels % % Causes of dyslipidemia Good 50.4 60.9 <0.05 Average 5.6 6.8 >0.05 Bad 44.0 32.3 <0.05 Consequence of dyslipidemia Good 14.4 44.3 <0.05 Average 8.8 7.7 >0.05 Bad 76.8 48.0 <0.05 Preventive and 473 treatment Good 14.8 54.6 <0.05 Average 40.3 11.4 <0.05 Bad 44.9 34.0 <0.05 Good level of knowledge on the causes, prevention, treatment and consequences of dyslipidemia increased and bad level reduced after health education on lipids. 3.3. Comparing prevalences of testing and treatment of dyslipidemia on sample before and after education Table 3.3. The prevalence of testing and treatment of dyslipidemia before and after education Testing and treatment Before health education (n= 350) After health Education (n= 350) P (Chi- square) % % No testing, undefine 84.7 70.9 <0.05 Test 15.3 29.1 <0.05 Reasons of testing Check periodical health 4.7 6.6 >0.05 Required by doctors 9.7 2.3 <0.05 By themselves 0.9 20.2 <0.05 Understand results of test 3.2 28.9 <0.05 - Dyslipidemia 3.2 16.3 <0.05 No understand results of test 12.1 0.3 <0.05 Treatment dyslipidemia No treatment 0.9 0.3 >0.05 Treatment 2.3 16.0 <0.05 Durg 1.9 2.3 >0.05 Drug and lifestyle change 0.4 13.7 <0.05 The prevalence of people going to hospital to test blood lipids increased from 0.9% to 20.2%, understanding of test results increased from 3.2% to 28.8%, treatment of dyslipidemia increased from 2.3% to 16%, drug therapy combined with lifestyle 474 changes increased from 0.4% to 13.7%. The difference between prevalences was statistically significance (p <0.05). 3.4. Dyslipidemia Table 3.4. The prevalence of dyslipidemia on sample before - after education Blood lipide Before health education (n= 350) After health Education (n= 350) P (Chi-square) IE % % (%) Desirable 60.7 72.3 <0.05 Dyslipidemia 39.3 27.7 <0.05 29.5 Including - Simple dyslipidemia 17.6 20.5 >0.05 High blood TC 3.2 6.0 >0.05 High blood LDL-C 1.4 1.1 >0.05 21.4 High blood TG 3.7 9.7 <0.05 Low blood HDL-C 9.3 3.7 <0.05 60.2 - Complex dyslipidemia 21.7 7.1 <0.05 67.3 Two components 13.4 5.1 <0.05 61.9 More than two components 8.3 2.0 <0.05 75.9 After education, the prevalence of dyslipidemia reduced from 39.3% to 27.7%; Intervention Effectiveness (IE) is 29.5%), including low blood HDL-C level decreased from 9.3% to 3.7%, (60.2% IE), high blood LDL-C level decreased from 1.4% to 1.1% (21.4% IE). High blood TG level increased. Comlex dyslipidemia (2.3 or 4 components) decreased from 21.7% to 7.1% (67.3% IE). Table 3.5. Dyslipidemia classification by levels of blood lipid components Components of lipide Classification Before health education (n= 350) % After health Education (n= 350) % P TC Desirable 56.0 60.9 >0.05 Borderline high 23.6 28.0 >0.05 475 High 20.4 11.1 <0.05 TG Desirable 74.5 71.4 >0.05 Borderline high 12.5 18.0 >0.05 High, very high 13.0 10.6 >0.05 HDL-C High 28.2 55.4 <0.05 Average 54.6 40.0 <0.05 Low 17.1 4.6 <0.05 LDL-C Desirable 67.6 82.9 <0.05 Borderline high 16.7 11.1 <0.05 High, very high 15.7 6.0 <0.05 The prevalence of high blood TC level decreased from 20.4% to 11.1%, low blood HDL-C level decreased from 17.1% to 4.6%, high blood LDL-C levels decreased from 15.7% to 6%. The difference between the prevalences before and after lipid education was statistically significant. The difference between prevalences of high blood TG levels before and after lipid education was not statistically significant. - Comparing mean values of lipid components on sample before-after education Table 3.6. Mean of lipid components on sample before-after education Lipide components Before health education (n= 350) % After health Education (n= 350) % P (F test) Mean (mg/dL) SD (mg/dL) M (mg/dL) SD (mg/dL) TC 196.9 50.3 191.4 43.3 >0.05 TG 129.3 86.5 136.8 75.2 >0.05 HDL-C 53.7 17.1 63.9 17.3 <0.05 LDL-C 119.4 48.2 100.6 45.4 <0.05 The mean of blood HDL-C levels increased (from 53.6 mg/dL to 63.9 mg/dL) and blood LDL-C levels reduced (from 119.4 mg / dL to 100.6 mg / dL) after lipid education. The mean of blood TC and TG levels did not change after lipid education (p >0.05). 476 4. Discussion The intervention of providing lipid education to the community and households was conducted for 12 months, from March, 2008 to May, 2009. The time of the intervention was not long but the improvement was significant. According to Sheri R. Colberg, the improvement was usualy after 6 weeks to 16 weeks and the improvement will be greater after 1 year or longer. To implement interventions in the community, the communication network of community health workers were built, they are included doctors, nurses, pharmacist of wards health center, private clinics, pharmacies and governments officers in wards; they were trained to communication in the community, households, offices, pharmacies, and clinics. Communication was integrated into the implementation of primary health care programs at the ward. These methods of intervention were implemented in many countries around the world and promoted lifestyle change and reduced others risk factors of coronary heart disease (CHD). In 2006, the physical activity and Nutrition programs of the National Center for Disease Control in American has implemented the intervention community to help change people's behavior: 20 social level interventions, 39 community level interventions, 54 organization level intervention, 65 individual level interventions purpose to promote community prevention of obesity, chronic diseases and other health problems through good nutrition and regularly physical activity. In Vietnam, the prevention of non-communicable disease strategy was issued in 2002, and the health sector is implementing and developing it. According to James M. Rippe, Theodore J. Angelopoulos and Linda Zukley (2007) the role of physicians and medical staff in lifestyle change interventions are very important. They recommend patients change their lifestyle and comply with the treatment regime . After one year the lipid communication and education have achieved some results. The prevalence of lipid disorders in people aged 20 and older decreased 11.6%. In the opinion of some authors, improved lipid levels depending on many factors, especially the combination of diet and physical activity, the effect of reducing dyslipidemia is very high when combined diet and physical activity has been noted. Some studies compared the benefits of physical activity and diet in the treatment of lipid disorders, some studies have shown lifestyle intervention with moderate diet combine with regularly physical activity less affect blood lipid levels than the more powerful lifestyle intervention (diet and physical activity more powerful than), improve better blood lipid levels and other risk. In concurrence to reducing the prevalence of lipid disorders, the difference in the mean value of increasing blood HDL-C level and reduction of LDL-C compared with before the intervention was statistically significant. This result is the main target in the treatment of lipid disorders, reducing CHD risk 477 factors. Important factor which reduce the prevalence of dyslipidemia is improvement of the level of knowledge of lipid such as good knowledge of dyslipidemia, risks, causes, prvention, and proper treatment increase after intervention; . Improving the knowledge base to change life habits. The intervention program in the U.S. has increased prevalences of physical activity among adults in the U.S. from 2001 to 2005. Research results in some developed countries, although intervention programes impact but still have some barriers affecting knowledge and awareness of dyslipidemia. Although knowledge of cholesterol in the U.S. has improved in recent years, the involvement of cholesterol treatment is still low in this case. The aforementioned study was conducted on seven groups in the UK, and showed that all participants realize that high cholesterol levels adversely affect health, but few people know their cholesterol levels, some doctors also do not mention tcholesterol problems. The study concluded that knowledge about cholesterol and the risk of CHD is not enough to change behavior. Lipid education in the city of Hue has changed the perception and behavior for people, increasing of detection and treatment of dyslipidemia in the community; after the intervention prevalence of self-lipid testing requirements, understand results of tests and proper treatment increase. It's necessary to maintain and promote behavioral change continuously through communication programs and activities of community health workers network. In the U.S., with the community intervention program, the prevalence of participants screened for cholesterol testing is increasing. The public health organizations have attempted to reduce population increases in blood cholesterol and increase awareness of blood cholesterol. There is a national objective screen 80% of adults aged 20 and older for cholesterol by 2010. 5. Conclusions The results after 12 months of intervention have been shown to lower the prevalence of dyslipidemia 11.6% (from 39.3% to 27.7%), hence the intervention was effective 29.5% not sure what this stat is for. The prevalence of high serum total cholesterol (TC) levels reduced from 20.4% to 11.1%, low serum high density lipoprotein cholesterol (HDL-C) levels reduced from 17.1% to 4.6%, high serum low density lipoprotein cholesterol (LDL-C) levels reduces from 15.7% to 6%, high serum triglicerides (TG) levels did not change. Average values of serum HDL-C levels increased (from 53.6 mg / dL to 63.9 mg / dL) and LDL-C levels reduced (from 119.4 mg / dL to 100.6 mg / dL) (p <0.05); average values of TC and TG did not change after intervention. Dietary and physical activity habits improved: reduced intake of saturated 478 fats (from 35.6% to 16.6%) and alcohol, higher intake of vegetables, and fish (from 43.5% to 69.7%). Higher percentage of exercise and sports, walking increases from 33.3% to 71.1%. People who had an average activities time of less than 30 minutes per day reduced from 26.9% to 2.9%; excessive intake of alcohol per day reduced from 37.1% to 6.6%; knowledge of dyslipidemia, dietary and physical activity also improved. There was an increase in the prevalence of people who came clinic to test blood lipid by themselves (from 0.9% to 20.2%) and know results of the test (from 3.2% to 28.8%); an increase in prevalence of treatment dyslipidemia (from 2.3% to 16%); among of them, the application of lifestyle changes in treatment increased from 0.4% to 13.7% (p<0.05). 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